PERIPHERAL NERVE TUMOR / INJURY / REPAIR SURGERY

Informed Consent Form

Form No: AOF-019	Rev. No / Date: 2026 v09 / 10.07.2026

PATIENT PROTOCOL NO	DATE
TURKISH ID / PASSPORT NO	DATE OF BIRTH
PATIENT'S NAME–SURNAME	SEX
DIAGNOSIS	(wide single cell)

1. Dear Patient,

It is your most natural right to be informed about your medical condition and about all medical / surgical treatments and diagnostic procedures proposed to you for the treatment of your illness. After learning the benefits and possible risks of medical treatments and surgical interventions, consenting or not consenting to the procedure to be performed is, again, your own decision. The purpose of this explanation is not to frighten or worry you, but to involve you more consciously in the decisions to be made concerning your health. If you wish, all information and documents concerning your health can be given to you or to a relative you deem appropriate. Although this form has been designed to meet the needs of most patients under most circumstances, it should not be regarded as a document containing the risks of all forms of treatment. Depending on your personal health condition, your physician may give you different or additional information. After learning the benefits and possible risks of diagnosis, medical treatment and surgical interventions, accepting or not accepting the procedures to be performed is your own decision. Except in situations of legal and medical necessity, you may refuse to be informed or withdraw your consent at any time. This form has been prepared to inform you about the risks of the surgery and about alternative treatment methods. Please read this form completely and carefully, and sign this consent form only after you have read it and after all your doubts about the procedure concerned have been resolved by the physician.

2. General Information About the Disease and the Treatment

The nerves that emerge from the spinal cord in the neck and lower-back regions and travel to the arms and legs are called peripheral nerves. Peripheral nerves originate from the spinal cord and, in the areas they reach, are responsible for producing movement by controlling the muscles; at the same time they carry the sense of touch in the skin and many sensory functions. Injuries, transections (cuts), tumors and cysts of these nerves, which provide the sensory and motor functions of our arms and legs, can be treated surgically. As a result of damage to the nerves concerned, loss of strength in the muscles that nerve controls, as well as severe pain, numbness and loss of sensation, may occur.

Peripheral nerve surgery is performed either to achieve re-innervation (restoration of the nerve's function) in nerve transections, or to remove peripheral nerve sheath tumors and again achieve re-innervation. Peripheral nerve injury is most frequently seen in the brachial plexus, median, ulnar, sciatic, radial and fibular nerves. The injured nerve will be joined together under the microscope so that it works again. Detailed information about the content of the surgery to be performed has been provided. From the options below, the one(s) appropriate to your condition will be evaluated:

Injury / tumor of the median nerve at the ……… level
Injury / tumor of the radial nerve at the ……… level
Injury / tumor of the ulnar nerve at the ……… level
Injury / tumor of the brachial nerve in the (supraclavicular / infraclavicular) region
Injury / tumor of the sciatic nerve at the ……… level
Injury / tumor of the femoral nerve at the ……… level
Injury / tumor of the fibular nerve at the ……… level
Injury / tumor of the ……………… nerve at the ……… level

So that the injured (or tumor-bearing) nerve works again, an anastomosis will be performed by bringing the healthy ends of the nerve face to face, or by placing nerve grafts (most frequently a sural nerve graft) in between. For diagnostic purposes, it may be necessary to take a small piece of nerve tissue for examination (sural nerve biopsy); in this case a sample is usually taken from the sural nerve, which runs along the outer side of the ankle, and a small area of sensory loss may occur just above the heel.

The existing disease (pathology) requiring the surgery may not be completely cured surgically. The pathological diagnosis after surgery may differ from what was predicted beforehand and may shorten life expectancy. It may require additional treatments (such as chemotherapy and radiotherapy). Your doctor, having evaluated your condition in detail, has decided on the most appropriate surgical treatment method for you and has recommended this approach to you.

3. Alternatives to the Surgery, If Any

As alternatives to the surgery, I have considered the following options:

As explained to me verbally by my physician, not having this surgery and accepting every associated risk,
Trying to resolve the problems through medication treatment and periodic radiological examinations,
Trying to relieve the pain or muscle spasm through medication,
Trying to relieve the complaints with physical therapy methods,
Doing strengthening exercises,
Other possible treatment options…

Nerve cells are generally not cells that can regenerate themselves. However, it has been shown that peripheral nerves can regenerate themselves at least partially. In partial damage or full-thickness transection of a peripheral nerve, serious functional losses arise because the functions of the nerves are completely lost. Without surgical treatment, the healing process will be very slow or will not occur at all. There is no medication treatment option available that is an alternative to the procedure. I have also considered the other treatment methods explained to me by my doctor. The advantages and disadvantages of these alternative methods were also explained to me by my doctor.

4. Expected Benefits of the Surgery

The expected benefit is an improvement in the patient's current neurological condition and complaints. The surgery is performed to eliminate the complaints and because of the expectation of preserving or improving the function of the nervous system.

WITH THE SURGERY TO BE PERFORMED;

To relieve the neural structures under compression,
To eliminate or reduce pain,
So that the injured (or tumor-bearing) nerve works again, to perform an anastomosis by bringing the healthy ends of the nerve face to face or by placing nerve grafts (most frequently a sural nerve graft) in between,
The aim is for the neurological deficits existing before the surgery (paralysis–loss of strength–numbness–loss of reflexes–urinary incontinence, etc.) and complaints such as pain and spasm to be completely resolved by the surgical treatment to be applied, or for their worsening to be halted.

5. Estimated Duration of the Surgery

The duration of the procedure to be performed may vary according to the disease and the patient's condition, and is on average .…........... - .…........... hours. In addition, the procedures to be carried out on patients by the anesthesia doctors before and after the surgery are not included in this period. Depending on the circumstances of the case, the procedure may take longer than the stated time. Your doctor will give you detailed information at the end of the procedure.

6. Risks and Complications of the Surgery

In addition to its benefits, the surgical procedure to be performed also carries risks that may arise.

Anesthesia risk: There are risks during and after local and general anesthesia procedures (due to the position given to the patient during surgery). In addition, in every form of anesthesia and in sedation, there are complications and harms that may arise from the drugs. The anesthesia procedure to be applied and the related risks and complications have been explained to me, and I approve the procedure recommended in this regard.
Bleeding: Although very rare, I am aware of the existence of a risk of bleeding, which may be severe, during or after my surgery. In the event of bleeding, additional treatment or a blood transfusion may be needed. In such a situation, I approve the necessary blood transfusion and other treatments. Some medications that I use and/or that need to be used during my treatment may increase the risk of bleeding through drug interactions and/or side effects. In some situations, it may be necessary to use blood-thinning medications earlier than expected, and this may also increase the risk of bleeding.
Blood clot formation: Blood clots may form after any type of surgery. Clots forming in the area of bleeding may obstruct blood flow and lead to complications such as pain, edema, inflammation or tissue damage. If the use of blood thinners is discontinued, the risk of clotting may increase.
Postoperative Neurological Deterioration: Due to problems such as bleeding at the surgical site, edema (pressure resulting from fluid accumulation) or vasospasm (narrowing of the blood vessels), nervous system functions may deteriorate after surgery.
Respiratory problems: After surgery, respiratory distress or pneumonia, which are usually temporary, may occur. Pulmonary embolism (blockage of the blood vessels of the lungs) may occur.
Cardiac complications: The surgery carries a low risk of leading to an irregular heart rhythm or a heart attack.
Death: Although very rare, there is a risk of death during or after the surgery.
Failure of the surgery: After surgery for a peripheral nerve injury/transection/tumor, there is a risk that pain, numbness, loss of muscle strength or other complaints may not be relieved; healing of the nerve may not be seen, and tearing-rupture due to inadequate blood supply or to stretching may occur. Improvement is expected after surgery in your pre-existing complaints such as pain and hypersensitivity to touch. However, sometimes there may be no improvement, and on the contrary an increase in pain and sensitivity may also occur. Time is required for the neurological deficits other than pain — that is, the sensory and strength losses — to recover. The speed at which the operated nerve can again conduct electricity recovers, progressing at about 1 mm per day. Physiotherapy — that is, the exercises performed to work your affected muscles — is of very great importance at this stage. During this process, despite the surgical treatment, electrical conduction may not resume, and as a result thinning and increased weakness may be seen in the muscles driven by your operated nerve.
Vascular injury: If the operated nerves follow an anatomical course adjacent to large blood vessels, injury to these vessels may occur during surgery, and repair of the vessel may additionally be required.
Increase in pain complaints: Although rare, pain complaints may increase after the surgery.
Infection: Infection may occur at the skin incision site as well as in the surgical field, and even in the bone within the surgical field. Risks related to infection include meningitis (inflammation of the membranes surrounding the brain and spinal cord) and the formation of empyema-abscess (accumulation of pus).
Nerve root injury: Nerve root injury may cause pain in the relevant extremity, weakness in the relevant muscle groups, and sensory disturbances in the relevant dermatomes (nerve areas).
Loss of sensation: When a sensory nerve (for example the sural nerve) is used for biopsy or graft harvesting, a loss of sensation may occur in a small, possibly permanent, area of the region to which that nerve carries sensation (for example, just above the heel).
Risk of cerebrospinal fluid leak: In interventions at the nerve root level (for example, brachial plexus avulsion), a leak of cerebrospinal fluid from the wound site to the outside environment may occur after surgery. For its treatment, a spinal (spinal cord) catheter or an additional intervention to repair the same wound site again may be required.
Recurrence, Residue (Remnant): After the surgery, the symptoms may reappear and additional surgery may be required.
I have also understood that during my surgery, in the event of an unexpected situation such as bleeding, injury to a neighboring tissue or organ, etc., my doctor may perform, beyond the planned procedure, other procedures required for my health, and I approve this.

I have understood and accept all the risks written above that may arise during and after the surgical procedure to be performed on me.

7. Consequences to Be Faced If the Surgery Is Not Performed

The patient's current complaints and clinical condition may not improve, and there may be a worsening. Peripheral nerves originate from the spinal cord and, in the areas they reach, are responsible for producing movement by controlling the muscles; at the same time they carry the sense of touch in the skin and many sensory functions. If this procedure is refused, loss of strength in the muscles controlled by the nerves concerned, as well as severe pain, numbness and loss of sensation, may occur.

8. Important Properties of the Medications to Be Used

If you have a previously identified drug allergy, you must be sure to inform your physician and your nurse about this. During your current treatment process, medications appropriate to the patient's medical condition (painkillers, antibiotics, medications supporting the circulation and the heart, blood products, intravenous fluid treatments, medications specific to your disease) will be given according to the reason for your admission or to newly developing conditions. During the use of medications, side effects may occur and cause damage to the heart, kidneys and other organs. New medications will be added to the treatment to correct organ damage. PROPHYLAXIS: Before and after your surgery, appropriate protective antibiotic treatment is applied with the aim of reducing the risk of surgical site infection. USE OF BLOOD-THINNING MEDICATION: If you are using anticoagulant, blood-thinning medications, different drug treatments or blood products may be given to you in order to counteract the effects of these medications. NERVE NUTRITION AND EDEMA: After the surgery, appropriate medications (anti-edema medications, medications supporting the circulation) that will reduce nerve edema and increase the nutrition of the nerve may be used. In this case, the blood sugar balance may be disturbed. If severe pain occurs after the operation, addictive medications sold on a green prescription may be used. In cases where there is no change in the weakness in the arms and legs after the surgery, or in newly developing weakness, anti-edema medications may be used. INTENSIVE CARE-DELIRIUM: For the psychological symptoms that may appear in elderly patients and in patients during prolonged intensive care stays, mental health-regulating medications recommended by a physician for mental and nervous disorders may be used. These medications may cause damage to the heart, kidneys and other organs. In addition to these, anesthesia-related medications are used. The general anesthesia (narcosis) drugs given during surgery may have toxic (poisonous) effects / side effects on organs such as the lungs, heart, brain, kidneys and liver. For this reason, a DANGER OF DEATH may arise.

I have informed my doctor about all my known allergies. I have also informed my doctor about the prescription medications I use, over-the-counter medications, herbal medicines, dietary supplements, illegal drugs, alcohol and narcotics/intoxicants. The effects of using these substances before and after surgery were explained to me by my doctor, and recommendations were made. I have received information about the important properties of the medications to be used for diagnosis and treatment during my stay in the hospital (what they are used for, their benefits, their side effects, how they are to be used).

9. Lifestyle Recommendations Critical to the Patient's Health

Tobacco and Tobacco Products: It has been explained to me that smoking tobacco and tobacco products (cigarettes, hookah, cigars, pipes, etc.) before or after my surgery may cause my recovery process to be prolonged. Anesthesia risks are greater in patients who smoke, and death due to anesthesia is seen more frequently. If you smoke, you should know that the success of your treatment/surgery will be lower than the general average success rate.

Follow your doctor's recommendations (exercise, nutrition program, etc.) and, if one has been requested, do not neglect your outpatient follow-up examination on the date requested of you.

I have received information about what I need to do regarding my lifestyle after my treatment/surgery (diet, bathing, medication use, mobility status and/or restrictions).

10. Patient-Specific Section

The patient's personal, individual circumstances are recorded at the end of the form under Section 14 — Signatures.

11. How to Access Medical Assistance on the Same Matter When Needed

Refusing the treatment/surgery is a decision you will make of your own free will. If you change your mind, you may personally reapply to our hospital / to the hospitals able to perform the treatment/surgery in question.

I have received information about how to access medical assistance on the same matter when needed (my own physician, a different physician, the clinic where I was treated, and in emergencies, 112).

12. Permissions

I authorize the Head of the Surgical Team, Responsible Specialist Doctor Dr. Özgür Akşan, and his team to perform my surgery.

I understand that this intervention is directed at eliminating my complaints and is performed with the intention of preserving or improving the function of the nervous system. I confirm that my doctor has explained all of the above information, that I have understood this information, and that all of my questions regarding this intervention have been answered. Therefore, I give my consent for PERIPHERAL NERVE TUMOR / INJURY / REPAIR SURGERY and for all different or additional surgeries and additional treatment interventions that my doctor deems necessary.

Use of tissue: Any tissue that is not required for medical diagnosis may be used for medical research within the framework of ethical rules. I consent to the use of any tissue, medical device or body parts that may have been removed during the surgical procedure.

Medical research: I consent to the review of clinical information from my medical records for the advancement of medical study, medical research and physician education, provided that the rules of confidentiality are observed.

Photography/Observers: I consent to the surgery to be performed being photographed or video-recorded for scientific, medical or educational purposes, provided that the images do not reveal my identity.

13. Consent Verification

I know the alternative treatment methods and their risks.
I know the risks and side effects of the intervention.
I know the probability of success and of failure.
I know what may happen if I am not treated.
I understand that the procedure to be performed may not carry a guarantee of cure.
I have understood everything that has been told to me.
My doctor has answered all of my questions.
My doctor explained what is written here to me item by item, in a clear, understandable and explanatory manner that I could comprehend.
I know the meaning of the Informed Consent form.
I have been informed about the approximate cost of the treatment.
I am making this decision of my own free will.
I had enough time, a reasonable period before the intervention, to obtain a second opinion.
I have read and understood the content of the Informed Consent form.
All the blanks on this form were filled in before I signed it, and I have received a copy.

14. Signatures

A) Patient-Specific Circumstances

The patient writes, in their own handwriting, their personal circumstances (allergies, medications used, previous surgeries, etc.). If there are no special circumstances, writing "NONE" is sufficient.

B) Handwritten Declaration

The patient writes the following sentence in their own handwriting:

"I have read this form carefully, I have been informed about THE SURGERY TO BE PERFORMED, my questions have been answered, and I give my permission for this procedure of my own free will."

C) Signatures

	Name – Surname	Signature	Date / Time
Patient
Legal Representative / Relative <br>(Degree of relationship: ……………………)
Head of the Surgical Team, Responsible Specialist Doctor	Dr. Özgür Akşan

Notes

Consent is obtained from the patient themselves if they are over 18 years of age; from the patient themselves and additionally from their legal representative if the patient is between 15 and 18 years of age; and from the legal representative in the case of an unconscious patient, a patient under 15 years of age who lacks decision-making capacity, and in medical emergencies.
All pages of the Information and Consent form must be signed by the person concerned, who writes "I have read it" on them.
This form must without fail bear the signatures of the physician who provided the information, the patient themselves and/or the patient's legal representative.
This form must be printed in two copies, and after both are signed, one must be given to the patient and the other placed in the patient's file.
This form has been prepared based on Nöroşirürjide Aydınlatılmış Rıza Formları [Informed Consent Forms in Neurosurgery] (2025, ISBN 978-605-4149-28-5), published by the Türk Nöroşirürji Derneği (Turkish Neurosurgical Society).